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March 7, 2017

In This Issue:

The House Energy and Commerce and the Ways and Means committees have scheduled to markup and approve new legislation that would repeal and replace the Affordable Care Act (ACA).

The Energy and Commerce and Ways and Means committees scheduled the markups for March 8 after releasing the legislative language the night of March 6. Previously, a budget resolution outlined specific instructions for the Energy and Commerce and Ways and Means Committees to draft legislative recommendations that the House Budget Committee could compile into one budget reconciliation package.

Neither bill has been scored by the Congressional Budget Office. Without the score the true cost and impact on patient health insurance coverage is unknown at this time. We expect the cost to be significant and the greatest impact on coverage to occur in the Medicaid program.

Specifically the new bill from the House Ways and Means would undo many of the ACA taxes and mandates—including the individual and employer mandate; enhance and expand Health Savings Accounts; and provide a monthly tax credit to individuals and families who don’t receive insurance through work or a government program.

The House Energy and Commerce Committee's legislation would undo the ACA'S Medicaid expansion by freezing new enrollment after two years and grandfathering in current enrollees; and create a new funding formula for states. It also sunsets "essential health benefits" provided for in the Medicaid program. The bill gives states funds to increase access to preventative services Federally Qualified Health Centers and repeals the Medicaid Disproportionate Share Hospital cuts for non-expansions States in 2018. States that have expanded Medicaid would have those cuts repealed in 2020.

The legislation would preserve provisions that allow young adults stay on their parents' health plans until age 26 and ban insurers from denying coverage or charge more to patients with preexisting medical problems. The legislation will penalize those who have a lapse in health coverage for more than two months.

On January 13, the House had passed a budget resolution to begin turning that vision into legislation through budget reconciliation. The Senate passed a fiscal 2017 budget resolution on January 11. The budget resolution is key to Republican plans because it will include budget reconciliation instructions—a procedural tool that allows the House and Senate to pass legislation addressing fiscal policy with a simple majority that cannot be filibustered by Senate Democrats.

The CAP urges Congress to consider the following policy principles as a framework for changes to the ACA:

  • Ensure access to affordable insurance
  • Maintain key insurance reforms (eg, pre-existing conditions)
  • Protect prevention and screening services
  • Stabilize and strengthen the individual insurance market
  • Reduce regulatory burdens on physicians

The CAP is prepared to assess and examine any replacement health care plan proposals to understand its impact on patients and pathologists. More updates on this issue will be published in future editions STATLINE.

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Collaboration will result in the first clinical data registry with measures developed by pathologists for pathologists

The CAP selected FIGmd, the leading provider of clinical data registries to specialty societies, to develop the first pathologist-specific clinical data registry, Pathologists Quality Registry. Designed specifically for the practice of pathology, this registry will ensure pathologists have a mechanism for quality improvement against the CAP established standards, while complying with requirements under the Medicare Quality Payment Program (QPP).

As the leading organization of board-certified pathologists, the CAP is focused on ensuring that pathologists can comply with new value-based payment models such as those enacted as part of the Medicare Access and CHIP Reauthorization Act (MACRA). As part of the CAP's advocacy strategy, a registry will ease compliance with quality reporting requirements and provide a simplified mechanism pathologists can use to improve quality and to meet the new Medicare program requirements.

The registry is a system used by physicians to collect medical and/or clinical data to foster improvement in the quality of care provided to patients. The CAP has submitted an application to the Centers for Medicare & Medicaid (CMS) to approve and authorize the registry as a reporting option in Medicare's QPP.

The Pathologists Quality Registry will provide a pathway for CAP members to meet new requirements under the QPP. The registry, available in 2017, will include 16 measures; eight of which are the current Physician Quality Reporting System (PQRS) measures, developed by the CAP.

"For the first time, pathologists have developed a benchmarking tool for their own fellow pathologists. The Pathologists Quality Registry is a performance improvement tool to ensure that our members can report their performance relative to the CAP's established performance measures, while benchmarking their performance against other pathologists," said CAP President Richard C. Friedberg, MD, PhD, FCAP. "We chose to work with FIGmd based on their experience with medical specialty societies, medical professional associations, and their innovative approach to making data collection meaningful. They are known for developing registries that are simple to implement and easy to use."

"Collecting, analyzing and most importantly acting on data insights is the future of health care," said Sanket Baralay, Founder and CEO of FIGmd. "We are delighted to partner with the CAP to launch the Pathologists Quality Registry. Our leading edge approach to data collection, analysis, and quality reporting will minimize data entry burdens and maximize registry participation benefits, for both individual pathologists and the profession as a whole."

The Pathologists Quality Registry is set to launch at the 2017 CAP annual meeting, before the 2018 MACRA performance period, to ensure that pathologists qualify for payment bonuses under Medicare’s Merit-based Incentive Payment System (MIPS).

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The Oregon Pathologists Association (OPA), along with the CAP, are actively opposing efforts by state lawmakers to link the out-of-network (OON) physician payment formula to Medicare.

The OPA supports pending state legislation (House Bill 2339), which would ensure that OON physician payment is based upon a "reasonable and customary rate" that includes consideration of the prevailing fees charged by providers in the geographic area in which the services are provided and other relevant aspects of the economics of the providers' practice. However, the OPA says it understands that lawmakers are contemplating amending the bill to provide a formula linked to Medicare. Both the OPA and the CAP oppose any such amendment.

"This alternative is inequitable and unworkable as Medicare rates are usually less than the in-network rate," writes OPA President Mohiedean Ghofrani, MD, MBA, FCAP, in a February 10 letter to Rep. Mitch Greenlick, the chair of the House Health Care Committee.

Moreover, Medicare does not uniformly cover some physician services that are currently covered by health plans, Dr. Ghofrani adds. "In some instances, Medicare rates, which are driven by federal budgetary requirements and not by the cost of providing care, are so low that they do not even cover the cost of the treatment provided,” he writes. "Thus, there is no incentive for health insurance plans to contract with physicians for their services."

In states where this issue has been addressed through legislation, policy makers have "recognized the need to maintain marketplace equilibrium between insurance payors and physician providers," Dr. Ghofrani notes. The National Association of Insurance Commissioners (NAIC) has recommended that states consider a payment formula based either on some percentage of a public, independent database of charges for the same or similar services in the same geographic area, or some percentage of usual, customary and reasonable (UCR) charges in the state.

"In setting a benchmark…state[s] should carefully consider the impact on the market," says the NAIC. "Setting a rate too high or too low may negatively impact the ability of facility-based providers and health carriers to agree on a contract."

For these reasons, even states as politically divergent as New York and Florida have keyed physician payment for OON services to a market-based charge formula that historically has been the basis for the usual and customary physician charge and health insurance plan payment, notes Dr. Ghofrani, adding that the OPA and the CAP support use of the 80th percentile of the FAIR Health Inc. database for determining usual and customary rates. FAIR Health is a national, independent not-for-profit corporation that has developed a database of billions of billed medical and dental services.

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A West Virginia bill designed to protect consumers from out-of-network health care bills could result in delays for patients receiving pathology services and fail to address network adequacy issues that are at the heart of balance billing problems, says the West Virginia Association of Pathologists (WVAP), with the support of the CAP.

House Bill 2327, introduced in the state legislature February 10 would add new disclosure requirements for health care providers, hospitals and insurers; require insurers to develop an access plan for consumers; and establish how surprise bills are to be handled in certain circumstances. Specifically, in order to be protected from surprise bills, a consumer would have to sign an assignment of benefits that would enable the provider to seek payment directly from the insurer.

However, in a February 22 letter to state Rep. Barbara Evans Fleischauer, one of the bill’s sponsors, the WVAP says it oppose the measure for several reasons. First, the legislation fails to recognize that pathology services in many cases cannot be delayed pending evaluation of the patient's health insurance. In fact, the bill directs that prior to providing non-emergency services (including pathology services), the provider must inform the patient of the availability of a written estimate of services.

"If enacted, this provision could result in a delay of certain pathology services that can jeopardize the care and treatment of the patient," writes Flavia Rosado, MD, FCAP, WVAP president, adding that physicians have an ethical obligation to perform services without delay when patient care and quality can be impaired.

Second, the legislation provides protection from balance billing only when the patient did not consent in writing in advance of the service. Because patients, for the most part, are unable to consent in writing for non-emergency pathology services that must be performed promptly when pathology findings are made during certain procedures, such bills would be deemed to be "surprise bills" under the legislation.

"Accordingly, this legislation would inappropriately categorize every pathology bill, because of the nature of the service, as a 'surprise bill,' writes Dr. Rosado. "By contrast, the State of Florida, under recently passed out-of-network legislation prohibiting balance billing, only considers out-of-network bills subject to such prohibition, when the patient did not have the control and ability to select the provider."

Third, the legislation fails to establish a strict network adequacy standard to assess health plans seeking state approval for network adequacy of hospital-based physicians, argues Dr. Rosado, noting that the American Medical Association advocates that health plans should be required to document to regulators that they have met requisite standards of network adequacy, including hospital-based physician specialties, at in-network facilities and ensure in-network adequacy is both timely and geographically accessible.

"The legislation should expressly compel health plans to document to state regulators that they have contracted with hospital-based physicians at in-network facilities prior to having the plan approved," writes Dr. Rosado.

Finally, the bill fails to cite the 80th percentile of FAIR Health Inc. databased for determining "usual and customary" rates at which out-of-network physicians would be paid by health insurance plans, says Dr. Rosado. The bill has been referred to the House Banking & Insurance Committee.

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On April 5, 2017, the CAP will present the Essential Tools for Pathologists Engaging in Grassroots Advocacy webinar that will provide a foundational training for members interested in becoming grassroots advocates. The 60-minute webinar will cover the basics of how Congress works, why grassroots matters and the tools and resources the CAP provides for members. We strongly encourage anyone attending the CAP Policy Meeting for the first time to participate, in order to gain a general understanding of grassroots advocacy before you arrive in Washington.

Whether you are DC bound or looking to get involved in your district, you'll want to hear from experienced advocates Joe Saad, MD, FCAP, Federal and State Affairs Committee Chair, Al Campbell, MD, FCAP, Grassroots Subcommittee Chair Federal and State Affairs Committee and moderator Michael Giuliani, CAP Advocacy Senior Director.

Register for the webinar.

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With a theme of Protecting the Practice of Pathology and Our Patients, let your voice be heard at the 2017 CAP Policy Meeting. From April 24–26, CAP members can connect with government leaders and policy experts to discuss the impact of federal regulation on their pathology practices.

New regulations are taking shape that will impact pathology reimbursements for years to come. Beginning in 2017, metrics outlined by a new reimbursement system for Medicare take effect.

At the 2017 CAP Policy Meeting, government leaders and policy experts will discuss how these major changes will impact your practice. You'll learn how to prepare your practice for these changes and how to make an impact on the legislation moving through Congress.

Registration is now open. Stay tuned for more updates.

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